Perspective: Who’s in charge of ED “boarders”?

By Charles A. Pilcher MD FACEP
August, 2016

An ED patient with a GI bleed and a hematocrit of 28 has been evaluated, the hospitalist has been contacted and initial orders for admission have been written by the night shift ED physician. No inpatient bed is available, but the hospitalist assures the ED doc, “I’ll come down and see the patient in the ED when I finish this admit.”

The ED doc goes on to the last patient of her night shift and repairs a simple laceration. As she leaves the ED, she tells her oncoming colleague “There’s a stable GI bleeder in Room 8 with a crit of 28 waiting for an inpatient bed. Dr. H will be down to see him when he finishes an admission. I’ve ordered a second hematocrit to be done in an hour. He might need blood, but I’ve only ordered a routine type and screen since he seems stable.”

The patient’s ED nurse goes on to care for other patients while awaiting word from the admitting office on an available bed for the patient with the GI bleed, who is at this point considered a “boarder.” That nurse leaves an hour later, only telling the oncoming RN that the patient in Room 8 is “waiting for an inpatient bed,” that Dr. H is “aware” and will be down to see his patient when he finishes an admit.

The next vital signs show a BP of 90/60 and pulse of 116. The new nurse pages the Dr. H (the hospitalist) and goes on to her next patient. Two hours after the first doc left the ED, the patient passes a large melanotic stool. The BP of 60/0 and pulse of 138.

The hospitalist has not answered the page, so he is paged stat to the ED. The ED doc now on shift, who has only the information given him by the off-going doc, is asked to intervene. The CBC ordered by the first ED doc is just now completed and the hematocrit is 16. Blood is not immediately available. Appropriate resuscitative efforts are undertaken but the patient dies in the ED.

Who is responsible? What could have been done better? If a lawsuit is filed, what defense will the 2 ED docs, the nurses and the hospitalist present? If none of the physicians are hospital employees, who will throw whom under the bus?


I have consulted on at least 3 similar cases where the basic question is “Whose at fault here?” In this example, the defense position of the first ED doc will be “I admitted the patient. He’s the hospitalist’s responsibility. And I informed my partner when I left.” The second ED doc says “She told me the patient was stable. I didn’t need to get involved. He was the hospitalist’s responsibility since he’d already been admitted.” The hospitalist says “I never saw the patient. If I had known the patient was this unstable, I could have gone to the ED and taken care of him.” Unfortunately the defense posited by each physician is “It’s not my problem.”

When episodes like this happen while ED patients are awaiting an inpatient bed and responsibility for the patient’s care is not clearly spelled out, patients die and lawsuits are filed.

Every hospital should have a policy addressing this situation. Even if that policy states that the hospitalist (in this example) is to be responsible for admitted but boarded patients, and even if orders are written by a hospitalist who HAS seen the patient, the ED doc maintains responsibility for boarded patients if for no other reason than one of “turf.” The ED environment is “home” to the ED doc. The ED nurses are the ones providing care. The doc works closely with these nurses and other staff. This is the team best equipped to deal with patients in the ED. Until actual departure to another unit of the hospital, that patient is still an ED patient. Transferring responsibility on paper is not the same as transferring responsibility in practice.

In the best case scenario, a co-management relationship should be spelled out in policy. It should define each physician’s role. Both parties must remain aware of the patient’s condition. The inpatient physician/hospitalist may write orders, which if time-sensitive (e.g., antibiotics, pain meds, heparin, respiratory treatments) must be carried out by the ED nurse. And the ED physician should be prepared to respond to any significant or urgent situations until the patient actually leaves the department.

Such policies are necessary because there is never any guarantee when a “boarding” patient will actually be admitted, transferred or go to the OR. The unexpected happens. Patients deteriorate. Thus, the only safe and right thing to do is to assure that the staff, including the physician, of the department where the patient is physically located care for him/her until he/she actually leaves.

Another situation worth mentioning is the patient on a “psychiatric hold.” At least in our region, some patients are being boarded in the ED for as long as 3-4 days. Not only is the eventual disposition unpredictable, but such boarding leads to multiple error-prone handoffs between shifts during such an extended stay.

Regarding the care of such boarded or co-managed patients, whether there is a written policy or not, all parties should document the parameters of their involvement in the care of such “pending admission” patients. While the ED nurses will definitely be involved, the ED physician and others (hospitalist, surgeon, cardiologist, etc.) must show that they clearly understand their role. Otherwise there is little defense if something goes wrong on their watch.

In general, it’s best to assume every patient physically remaining in the ED continues to be the ED physician’s responsibility, admitted or not. A bedside handoff where the departing physician introduces the patient to the new physician is best practice. And ditto for the nurse. This is true even if they have “given report” to the receiving unit.

Good care and good handoff policies can keep this from happening. The lack thereof leads to nothing but tragedy, finger-pointing and an easy settlement for a plaintiff.

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